Passport Health Plan’s mission is to improve the health and quality of life of our members. With this in mind, Passport Health Plan has adopted the enclosed Clinical Practice Guidelines. The intent of the guidelines is to support your efforts in the care and education of our members and to reduce variation in diagnosis and treatment.

The Plan makes every effort to ensure that current scientific data and expert opinion is the basis for each guideline. Each guideline is evaluated as new data becomes available or at a minimum of every two years. Passport Health Plan monitors provider compliance and member outcomes related to these clinical guidelines for quality improvement initiatives and recredentialing efforts.

These guidelines are intended to assist the practitioner in clinical decision-making and attempt to define clinical practices that apply to most patients in most circumstances.

The treating practitioner should make the ultimate decision regarding the care of a particular patient. If you would like a hard copy of the guidelines, please contact Utilization Management at (571) 385-3921.

Abdominal Aortic Aneurysm

Acute Bronchitis

Acute Pharyngitis

Attention-Deficit/Hyperactivity Disorder (ADHD)



Attention-Deficit/Hyperactivity Disorder (ADHD)

Cancer Screening


Child & Adolescent Preventive Health Clinical Practice
Guidelines / EPSDT Periodicity Schedule

Chronic Kidney Disease

Congenital Hypothyroidism

Congestive Heart Failure (CHF)

Chronic Obstructive Pulmonary Disease (COPD)



EPSDT Interval Screening Calculator


Gonococcal Ophthalmia Neonatorum

Heart Failure


High Blood Pressure


Immunizations and Vaccinations

Lead Screening

Low Back Pain

Obesity and Overweight

Opioid Use


Otitis Media

Panic Disorder


Prenatal and Perinatal Care

Post Traumatic Stress Disorder (PTSD)

Schedule of Preventive Pediatric Visits


Sexually Transmitted Infections

Sickle Cell Disease

Substance Use Disorder


Use of Atypical Antipsychotic Medications in Children and Adolescents

Viral Upper Respiratory Infection VURI in Children

Vision Screening